Sarah Baum

Change in abortion services after implementation of a restrictive law in Texas

OBJECTIVES In 2013, Texas passed omnibus legislation restricting abortion services. Provisions restricting medical abortion, banning most procedures after 20 weeks and requiring physicians to have hospital-admitting privileges were enforced in November 2013; by September 2014, abortion facilities must meet the requirements of ambulatory surgical centers (ASCs). We aimed to rapidly assess the change in abortion services after the first three provisions went into effect. STUDY DESIGN We requested information from all licensed Texas abortion facilities on abortions performed between November 2012 and April 2014, including the abortion method and gestational age (< 12 weeks vs. ≥ 12 weeks). RESULTS In May 2013, there were 41 facilities providing abortion in Texas; this decreased to 22 in November 2013. Both clinics closed in the Rio Grande Valley, and all but one closed in West Texas. Comparing November 2012-April 2013 to November 2013-April 2014, there was a 13% decrease in the abortion rate (from 12.9 to 11.2 abortions/1000 women age 15-44). Medical abortion decreased by 70%, from 28.1% of all abortions in the earlier period to 9.7% after November 2013 (p<0.001). Second-trimester abortion increased from 13.5% to 13.9% of all abortions (p<0.001). Only 22% of abortions were performed in the states six ASCs. CONCLUSIONS The closure of clinics and restrictions on medical abortion in Texas appear to be associated with a decline in the in-state abortion rate and a marked decrease in the number of medical abortions. IMPLICATIONS Supply-side restrictions on abortion - especially restrictions on medical abortion - can have a profound impact on access to services. Access to abortion care will become even further restricted in Texas when the ASC requirement goes into effect in 2014.

Impact of Clinic Closures on Women Obtaining Abortion Services After Implementation of a Restrictive Law in Texas

OBJECTIVES To evaluate the additional burdens experienced by Texas abortion patients whose nearest in-state clinic was one of more than half of facilities providing abortion that had closed after the introduction of House Bill 2 in 2013. METHODS In mid-2014, we surveyed Texas-resident women seeking abortions in 10 Texas facilities (n = 398), including both Planned Parenthood-affiliated clinics and independent providers that performed more than 1500 abortions in 2013 and provided procedures up to a gestational age of at least 14 weeks from last menstrual period. We compared indicators of burden for women whose nearest clinic in 2013 closed and those whose nearest clinic remained open. RESULTS For women whose nearest clinic closed (38%), the mean one-way distance traveled was 85 miles, compared with 22 miles for women whose nearest clinic remained open (P ≤ .001). After adjustment, more women whose nearest clinic closed traveled more than 50 miles (44% vs 10%), had out-of-pocket expenses greater than

Women’s Experience Obtaining Abortion Care in Texas after Implementation of Restrictive Abortion Laws: A Qualitative Study

100 (32% vs 20%), had a frustrated demand for medication abortion (37% vs 22%), and reported that it was somewhat or very hard to get to the clinic (36% vs 18%; P < .05). CONCLUSIONS Clinic closures after House Bill 2 resulted in significant burdens for women able to obtain care.

Delays and barriers to care in Colombia among women obtaining legal first- and second-trimester abortion.

Background In November 2013, Texas implemented three abortion restrictions included in House Bill 2 (HB 2). Within six months, the number of facilities providing abortion decreased by almost half, and the remaining facilities were concentrated in large urban centers. The number of medication abortions decreased by 70% compared to the same period one year prior due to restrictions on this method imposed by HB 2. The purpose of this study was to explore qualitatively the experiences of women who were most affected by the law: those who had to travel farther to reach a facility and those desiring medication abortion. Methods In August and September 2014, we conducted 20 in-depth interviews with women recruited from ten abortion clinics across Texas. The purposive sample included women who obtained or strongly preferred medication abortion or traveled ≥50 miles one way to the clinic. The interview guide focused on women’s experiences with obtaining services following implementation of HB 2, and a thematic analysis was performed. Results Women faced informational, cost and logistical barriers seeking abortion services, and these obstacles were often compounded by poverty. Two women found the process of finding or getting to a clinic so onerous that they considered not having the procedure, although they ultimately had an abortion; another woman decided to continue her pregnancy, in part because of challenges in getting to the clinic. For two women, arranging travel required disclosure to more people than desired. Women who strongly preferred medication abortion were frustrated by the difficulty or inability to obtain their desired method, especially among those who were near or just beyond the gestational age limit. The restricted eligibility criteria for medication abortion and difficulty finding clinics offering the method created substantial access barriers. Conclusions Medication abortion restrictions and clinic closures following HB 2 created substantial barriers for women seeking abortion in Texas.

Perspectives among a Diverse Sample of Women on the Possibility of Obtaining Oral Contraceptives Over the Counter: A Qualitative Study

To evaluate delays before first‐ or second‐trimester legal abortion and barriers to care in Colombia.

A harm-reduction model of abortion counseling about misoprostol use in Peru with telephone and in-person follow-up: A cohort study

BACKGROUND There is increasing support among stakeholders in the United States to make oral contraceptives (OCs) available over the counter (OTC). Previous research on the topic has focused on representative samples of U.S. women, Latina women, low-income women, and abortion clients. However, little is known about the perspectives of African American women, Asian American women, and young women. METHODS We conducted 14 focus group discussions with 138 women. Twenty-three percent of participants were ages 18 or younger, 61% were African American, and 26% were Asian American/Pacific Islander. Community organizations recruited participants through convenience sampling and hosted the discussions. Focus groups were transcribed and coded thematically. FINDINGS Women reported potential benefits of OTC access, including convenience and privacy. Many believed OTC availability of OCs would help to reduce unintended pregnancy and help to destigmatize birth control. Participants also expressed concerns about OTC access, such as worry that first-time users and young adolescents would not have enough information to use the pill safely and effectively, as well as concerns about whether women would still obtain preventive screenings. Women were also worried that the cost of OTC OCs would be higher if insurance no longer covered them. CONCLUSIONS Overall, women were interested in the option of obtaining the pill OTC. Future research and advocacy efforts should explore womens concerns, including whether adolescents can effectively use OTC pills and ensuring insurance coverage for OTC contraception.

Acceptability and clinical outcomes of first- and second-trimester surgical abortion by suction aspiration in Colombia ☆

Background In Peru, abortion is legal only to preserve the life and health of the woman. A non-profit clinic system in Peru implemented a harm-reduction model for women with unwanted pregnancy that included pre-abortion care with instructions about misoprostol use and post-abortion care; they started offering telephone follow-up for clients in 2011. This study aimed to evaluate the effectiveness and safety of the harm-reduction model, and to compare outcomes by type of follow-up obtained. Methods Between January 2012 and March 2013, 500 adult women seeking harm-reduction services were recruited into the study. Telephone surveys were conducted approximately four weeks after their initial harm-reduction counseling session with 262 women (response rate 52%); 9 participants were excluded. The survey focused on whether women pursued an abortion, and if so, what their experience was. Demographic and clinical data were also extracted from clinic records. Results Eighty-six percent of participants took misoprostol; among those taking misoprostol, 89% reported a complete abortion at the time of the survey. Twenty-two percent obtained an aspiration after taking misoprostol and 8% self-reported adverse events including hemorrhage without transfusion, infection, or severe pain. Among women who took misoprostol, 46% reported receiving in-person follow-up (in some cases both telephone and in-person), 34% received telephone only, and 20% did not report receiving any form of follow-up. Those who had in-person follow-up with the counselor were most likely to report a complete abortion (<0.001). Satisfaction with both types of follow-up was very high, with 81%-89% reporting being very satisfied. Conclusions Liberalization of restrictive abortion laws is associated with improvements in health outcomes, but the process of legal reform is often lengthy. In the interim, giving women information about evidence-based regimens of misoprostol, as well as offering a range of follow-up options to ensure high quality post-abortion care, may reduce the risks associated with unsafe abortion.

Providers' perspectives on male involvement in family planning in the context of a cluster-randomized controlled trial evaluating integrating family planning into HIV care in Nyanza Province, Kenya

OBJECTIVE(S) Since partial decriminalization of abortion in Colombia, Oriéntame has provided legal abortion services through 15 weeks gestation in an outpatient primary care setting. We sought to document the safety and acceptability of the second trimester compared to the first-trimester surgical abortion in this setting. STUDY DESIGN This was a prospective cohort study using a consecutive sample of 100 women undergoing surgical first-trimester abortion (11 weeks 6 days gestational age or less) and 200 women undergoing second-trimester abortion (12 weeks 0 days-15 weeks 0 days) over a 5-month period in 2012. After obtaining informed consent, a trained interviewer collected demographic and clinical information from direct observation and the patients clinical chart. The interviewer asked questions after the procedure regarding satisfaction with the procedure, physical pain and emotional discomfort. Fifteen days later, the interviewer assessed satisfaction with the procedure and any delayed complications. RESULTS There were no major complications and seven minor complications. Average measured blood loss was 37.87 mL in the first trimester and 109 mL in the second trimester (p<.001). Following the procedure, more second-trimester patients reported being very satisfied (81% vs. 94%, p=.006). Satisfaction was similar between groups at follow-up. There were no differences in reported emotional discomfort after the procedure or at follow-up, with the majority reporting no emotional discomfort. The majority of women (99%) stated that they would recommend the clinic to a friend or family member. CONCLUSIONS Second-trimester surgical abortion in an outpatient primary care setting in Colombia can be provided safely, and satisfaction with these services is high. IMPLICATIONS This is one of the first studies from Latin America, a region with a high proportion of maternal mortality due to unsafe abortion, which documents the safety and acceptability of surgical abortion in an outpatient primary care setting. Findings could support increased access to safe abortion services, particularly in the second trimester.